What a doctor thinks of the junior doctors' strike

"This strike demonstrates quite how serious things must be if a dusty, musty old institution like the BMA can do something as extreme as striking," says Dr Max

By
Dr Max Pemberton

18/01/2016

Carl Court / StaffGetty Images

If you believe some sections of the media, the junior doctor's strike was the result of a fanatical, ultra-left wing contingent in the BMA who were hell bent on disrupting the government's plans to renegotiate contracts. The strike is the result of political animosity, rather than for any justifiable concerns regarding working conditions, pay or patient safety, or so this argument goes.

For those of us in the know, this is utterly ludicrous. It's clearly an attempt to smear the BMA, and therefore discredit the strike, by dismissing it as a loony left wing prank. But the BMA is not like other unions, who may well be dominated by left wing politics.

It is true that there is a contingent of hard left doctors in the BMA, but they are small in number and certainly do not exert the kind of incredible power that some seem to think. They are tolerated and their views listened to, but they are not taken seriously. For several years my partner, also a doctor, was involved in the BMA. I have also had numerous dealings with them over the years, both as a journalist and as a doctor. If anything, the BMA are dull, reactionary and conservative.

In this way, they are – as you would expect - fairly representative of the medical profession. After all, doctors are hardly known for being radical, are they? If anything, they are cautious, middle of the road types of people: gentle and thoughtful. They tend to be conservative, both in terms of attitude and politics. Over the years one of my main issues with the BMA is not its radical, aggressive politics but the complete opposite – too often it is slow to act, wary of rocking the boat and inclined to navel-gaze rather than be proactive. There is a fairly even spread of political persuasions in the BMA and the tedious, labyrinthine processes to get anything in motion often mean there's a lot of discussion and not much action.

It's important that the junior doctor strike is seen in this context because it shows quite how extraordinary it is, and also demonstrates quite how serious things must be if a dusty, musty old institution like the BMA can do something as extreme as striking. It's not like doctors have a track record of being disruptive in this way. The last industrial action taken by the medical profession was in 1974 – over an entire generation ago.

Over the past six months since the dispute erupted between the BMA and the government, there has been a lot of claims and counter claims. It's sometimes hard to know what or who to believe. I've been saddened by some of the behaviour from the Department of Health. They've released statements to the press outlining changes to the deal before speaking directly to the BMA, meaning the BMA have not had enough time to examine the details before being asked to comment on them. They have engaged in attempts at media manipulation, for example when it transpired that a controversial letter to a newspaper from an 'independent' medic to build a hard edged case against the strike in the wake of the Paris terror attacks had in fact been edited by Whitehall. On the day of the strike, a Department of Health aide was also caught on camera trying to stop an interviewer asking difficult questions about why Jeremy Hunt had refused to be interviewed.

And they have also been fundamentally disingenuous, for example, when the health secretary, Jeremy Hunt, announced an offer of an 11% pay rise. This was a stroke of genius, as it looked extraordinarily generous while simultaneously making the junior doctors look greedy and as though this whole dispute was about money, when it is also about fundamental aspects of patient safety. In fact, the pay rise offer turned out to be an increase in the basic pay of junior doctors, as an attempt to offset the decrease in overall pay when the premium rates for antisocial hours were cut. Doctors were quick to point out that firstly this was therefore not a pay rise and secondly that it was not actually enough to make up for the loss of pay they would experience, meaning they were still facing pay cuts.

The BMA, in contrast, has been woefully naive and slow to react to these claims, always appearing on the back foot and struggling to counter the spin. In the age of 24-hour news, their press department has too often been simply too slow in rebutting and refuting the claims coming out of the well—oiled government spin machines.

But the most important question to answer is why on earth has the government picked this fight? It seems a tremendous gamble to pick on one of the hardest working groups in the NHS with whom the general public have great sympathy. And now that they have experienced resistance, why aren't the government just giving in? In a nutshell, it's because this is about far more than just junior doctors. As ironic as it sounds, I feel it's about the government showing that they can be trusted with the NHS.

The origins of the current problems over the junior doctor contract can be traced back to the Government's election pledge of introducing a 7-day-a-week NHS. When they first announced this proposal many questioned where the money would come from to pay for this, and the government were unable to provide any answers. It seemed particularly strange given that not only was there no extra money in the NHS pot, but we have been constantly told that the NHS needs to make savings – to the tune of £30 billion over the next five years. It just didn't make sense.

The answer they have stumbled on is to change the contract for the junior doctors so that there is less distinction between weekdays and weekends and to increase what 'normal' hours are defined as, so that doctors can work later without them having to be paid higher rates. So, with no extra money, doctors could now be expected to work Saturdays and late at night, thus helping the government deliver its election pledge. In effect, it was using the same number of doctors, just spreading them more thinly over seven days.

Unfortunately the proposed changes meant that the vast number of junior doctors who already work weekends or evenings would be significantly out of pocket. This entire thing is completely avoidable though because it's based on a fundamental misunderstanding of what sort of NHS we really need. The government has been obsessed with a 7-day NHS but this is a ludicrous pipe dream they should give up on. They made the same promise five years ago and it had failed to materialise and so they are clearly determined that this won't happen again. But given the absence of money, let alone doctors, we need to be pragmatic.

The apparent statistics showing increased mortality that caused so much panic and put weekend NHS care on the political agenda have since been found to be flawed, but even so, there's no harm in ensuring we have the best care available to those that need it at weekends and out of hours. But what started out as a patient safety issue has morphed into a healthcare wish list of luxuries we simply don't have the money for and has resulted in the current fracas with the junior doctors. We need to make the distinction between opening for safety and opening for convenience, with us prioritising the former and accepting the latter as a luxury.

It would seem far more sensible to look at areas of critical care – A&E, cardiac and stroke wards, maternity services, intensive care and so on – the kinds of places where people are acutely unwell and need regular senior input – and focus our attention there. You'll find that many of these areas already operate a 7-day-a-week NHS anyway as far as the doctors are concerned. Paediatrics, for example, has long ago accepted the need for consultant input at all hours, and have structured their services accordingly without recruiting. We also need to accept that some specialities – such as dermatology or rheumatology – do not need to provide 7-day cover. While it might be nice, people simply do not need to have a dermatology outpatient appointment on a Sunday afternoon. Rather than promising the same old service just on more days, we should be prioritising the areas were people are sickest and therefore in most need.

But this then exposes an even bigger issue: doctors are not actually the problem with delivering this anyway.

Doctors do not operate in a hospital on their own. They are part of a much bigger system and are reliant on many other professionals and services to do their job. It's no use having a team of doctors seeing patients if there aren't the services in place that they need in order to do their jobs. You can't safely discharge older patients unless they've been assessed by an occupational therapist, for example. To run a truly 7-day NHS you'd also need to ensure that there were radiology services so that people could have scans. You'd need fully staffed endoscopy suite. You'd need to have fully staffed physiotherapy, speech and language therapy and psychology departments. You'd need full capacity admin teams to book in appointments and porters to collect and transfer patients. When you see it like this, the doctors are just a tiny cog in a very large machine.

The government have made a mistake. They wanted to improve the NHS and improve patient safety and they latched on to the idea of a 7-day NHS without really thinking it through or fully understanding the real issues. They should focus all their attention on ensuring the critical care aspects of what hospitals do - which is where the sickest and most in need patients are - is fully staffed and operating at maximum efficiency. Junior doctors are already working flat out in these areas. Seen like this the junior doctor strike is at the very heart of questions about the sort of NHS we need and want. I think the government has got it woefully wrong and is now locked in a battle with juniors when there is absolutely no need. They need to back down and channel their energies into redesigning the kind of out of hours service that are actually needed.

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